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Clinic > Knee > Flashcards

Knee Flashcards

1
Q

three joints of the knee

A

• Two (three) joints:
– Tibiofemoral joint (TFJ)
– Patellofemoral joint (PFJ)
– (Superior tibiofibular joint)

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2
Q

tibiofemoral joint

A

• TFJ is the articulation between the tibia and femur
– 1° Weight-bearing synovial joint
– Modified hinge joint • Flexion/extension
• Medial/lateral rotation
• Abduction/adduction (passive motion)

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3
Q

patellofemoral jt

A

• PFJ
– Articulation between the patella and femur
– Modified plane joint
• The patella acts to improve the leverage of
the quadriceps muscles
─ PFJ implicated during loaded flexion of the knee,
e.g. climbing stairs, walking up/ down hills ─ ImportantclinicallytodifferentiatefromTFJ

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4
Q

superior tibiofibular jt

A

• Superior tibiofibular joint
– Articulation between the tibia and fibula
– Plane joint
• Not most common cause of knee pain but shouldn’t be neglected

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5
Q

muscles of the knee

A 
– Flexors:
• Hamstrings
• Gastrocnemius • Gracilis
• Sartorius
– Extensors:
• Quadriceps
– Medialrotators
• Semitendinosus, semimembranosus (medial hamstrings)
• Gracilis
• Sartorius
• Popliteus
– Lateralrotators
• Biceps femoris (lateral
hamstring)
• Popliteus
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6
Q

ligs of the knee

A 
ACL 
PCL 
LCL 
MCL 
M meniscus
L Meniscus
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7
Q

Bursae of the knee

A 
suprapatellar bursa 
Deep infrapatellar bursa 
Subsartorial 
Semimemb
Subcutaneous prepatellar 
subcutaneous infraptella
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8
Q

screw home mechanisms

A
  • A locking mechanism occurs in the tibiofemoral joint between 20° of flexion and full extension (0°)
  • Most prominent around last 5° ext • Necessary for stability
  • Reduction in friction
  • Improved efficiency
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9
Q

locking unlocking

A

12

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10
Q

PE

A

• Observation
– Walking from the waiting room
– Sitting in chair/on plinth
– Removing shoes etc.
• Patient history
• Gait analysis
– Lower limb functional task that nearly everyone does.
– Formal observation
• Baseline functional test – can you replicate the primary complaint? – e.g. Sit to stand, walking, squatting
• Active Range of Motion
– Quantity and quality (what limits motion e.g. pain, caution, can they maintain the position (severity), does the pain go away instantly (irritability))
• Passive Range of Motion
– Quantity and quality (what limits, e.g. pain, caution, some clinicians
value ‘end-feel’)
– Differentiate between active and passive system?
• Resisted tests (MMT)
– Isometric &/or Isotonic (pain vs. weak) – Functional (pain vs faulty patterns)
– Global lower limb
• Clearing tests
• Palpation
• Accessory Movements (joint play)
• Special tests (specific to pathology/clinical reasoning)
– Abundance of “special tests”
– Be cautious, potential for false positives (e.g. positive McMurray’s without relevant meniscal pathology)
• Neurological assessment and/or Neurodynamic tests

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11
Q

Causes of acute knee pain

A 
trauma - #'s 
- patella, femoral condyles, tibial plateau, avulsion #
Patella disclocation 
Ligament damage
Haemarthrosis 
Muscle strain/contusion 
Meniscal damage
Fat pad damage 
bursitis 
tendon rupture
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12
Q

ACL problem

A

• Most commonly injury knee ligament
– 52 per 100,000 in Australia (Janssen et al. Scand J Med Sci Sports. 2012 22(4), p 495)
– Incidence rises through adolescence and early adulthood – males > females.
– Highest incidence (descending order)
• Skiing • AFL
• Rugby • Netball • Soccer

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13
Q

ACL Dx

A

• Clinical diagnosis
– «»
– 1° complaint giving way/instability
– ± pain
– Swelling++/Heamarthrosis
– Special tests; Lachman’s test, Anterior Drawer Test, pivot shift test
• MRI, X-ray (sulcus sign)
• Three grades of ligament injury
http://www.youtube.com/watch?v=L51ASg2_07Q
• Outcomes: KOOS, LLTQ, SF-36, functional measures

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14
Q

ACL Rx

A

• Phase1(Acutephase)goals
• Control pain and swelling, Restore pain free ROM, Improve flexibility, Normalize gait mechanics (WBAT w crutches), Establish good quadriceps activation
• Phase2(Sub-acute/strengtheningphase)goals
• Avoid patella femoral pain, Maintain ROM and flexibility, Restore muscle strength,
Improve neuromuscular control
• Phase3(Limitedreturntoactivityphase)goals
• Avoid patella femoral pain, Maintain ROM and flexibility, Progress with single leg strengthening to maximize strength, Progress dynamic proprioception exercises to maximize neuromuscular control, Initiate plyometrics* and light jogging*
• Phase4(Returntoactivity/sportphase)goals
• Maintain adequate ROM, flexibility and strength, Continue progressive/dynamic strengthening, proprioceptive, plyometric and agility training, Achieve adequate strength to return to sport (pending physician’s clearance)

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15
Q

ACL evidence

A
  • Conservative vs. Surgery 6 – 16 months follow-up (Karanikas et al., Sportverletzung-Sportschaden 2005, 19(1) p15).
  • n = 12 conservative vs. n = 21 operative
  • Operative group scored better for ligamentous stability
  • Conservative group had > muscle strength (knee ext & flx, ankle plantarflexors)
  • Conservative vs. Surgery 11 year follow-up (Kessler et al. Knee Surg Sports Traumator Arthrosc, 2008 16, p442)
  • n = 109 (60 surgery, 49 conservative) Isolated ACL rupture – same rehab program
  • 11 years after ACL rupture, surgery group had better stability but more Knee OA (>Grade II), no difference in physical activity level (both groups decreased physical activity level)
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16
Q

Patella # - problem

A 
• Fracturesofthedistalfemur,proximaltibiaandpatella make up 6.7% of all LL fractures
• 47%proximaltibia
• 32%distalfemur
(Vun et al. http://www.bjjprocs.boneandjoint.org.uk/content/95-B/SUPP_12/10)
• Cause (e.g. fall, RTA)
• Patella–directblow
• Tibialplateau–compression
• 21%Patella
17
Q

patella # dx

A

• Clinical diagnosis
– Instant PAIN+
– Swelling++/Heamarthrosis
– Quads weakness, or inability to extend leg
– Pain++ on palpation, depending on fracture type might be able to feel gap
– OWATTA KNEE RULES
• X-Ray – Confirmation
– Referral Orthopaedic Specialist
• Outcomes:KneeSocietyClinicalRatingScale(KSCRS)
<>, WOMAC, KOOS, LLTQ, SF-36

18
Q

OTTAWA knee rules

A 
age 55 or older
isolated tenderness to patella 
tenderness of head of fibula
inability to flx 90 degrees
Inability to WB both immediately and in ED for 4 steps
19
Q

Patella # Rx

A 
• Non-displaced (retains normal form and position) – Brace Knee Immobilizer (full extension) 4 – 6 weeks
– Period of NWB (7 days) than WBAT
– Physiotherapy • ROM
• Strengthening
• Restore normal function
• Displaced
– ORIF (4 – 6 weeks immobilizer brace)
– Physiotherapy
• Same as above
20
Q

Patella # evidence

A
  • Percutaneous vs. Open surgery 2 year follow-up (Luna-Pizarro et al. Journal of Orthopaedic 2006 20(8), P529)
  • n = 53 patients (displaced patella fracture)
  • Percutaneous repair was associated with shorter surgical time, less pain, better mobility angle (flexion > extension), better KSCRS at 4 and 8 weeks follow up.
  • Knee society clinical rating scale was greater in the percutaneous group at 12 and 24 months
21
Q

Chronic/idiopathic causes of knee pain

A 
OA
patella tendinopathy
ITB syndrome 
PFPS 
Chrondromalacia patellae
Hypermobility
knee deformity - genu varum/valgum
Osteochondritis desicans
Osgood schlatter disease
22
Q

OA - problem

A

• Significant problem (older population)
– 1.4 million Australians (2009)
• Two types (Felson et al. 2000, Annals of Internal Medicine, 133 (8) p635)
– Primary – idiopathic, gradual deterioration, affects many joints (older age) – Secondary – following injury, localised to one joint (younger age)

23
Q

OA Dx

A

• Clinical diagnosis (Think age, main symptoms: pain, stiffness, limited movement of the affected joint)
• X-ray (Kellgren & Lawrence OA Grades)
• Outcomes: WOMAC, KOOS, LLTQ, 6MWT, TUG,
STS

24
Q

OA Rx

A

• Treatment (Zhang et al., 2008)
• 12 Non-pharmacological therapies
– advice and education, self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening, water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal
• 8 Pharmacological modalities (NSAID, topical NSAID, intra- articular injections)
• 5 Surgical modalities (arthroscopy, partial joint replacement, total joint replacement)

25
Q

OA evidence

A

• RCT exercise vs. no exercise (Nejati et al., 2015)
• Both groups received the same treatment except exercise
• Exercise group had > improvement in pain, disability, walking, stair
climbing, and sit up speed at all time points (1, 3, 12 months).
• Physiotherapyprogramvs.homeexerciseprogram (Deyle et al. 2005 Physical Therapy 85 (12), p1301)
• 2 Groups – supervised exercises with manual therapy vs. home exercise program over 4 weeks
• Both groups improved
• Supervised group had significantly greater improvements on 6MWT and WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)

26
Q

PFPS: problem

A

• Most frequently diagnosed condition in patients <50 years
with knee complaints (adolescent
population) (Lankhorst et al., JOSPT 2012 42(2), P81)
• Females > Males (Lankhorst et al., 2012)
• Incidence of 25 – 43% in sports medicine and during military
training (Devereaux et al., 1984: Thijs et al., 2007)

27
Q

PFPS Dx

A

• Clinical presentation (think age)
– Anterior knee pain: Peripatellar pain ,hard to describe
– Pain on loaded or prolonged flexion (running,stairs,sitting)
– Weak medial and tight lateral
– Poor patellar tracking (q-angle)
–Weak hip muscles /altered hip and/ or foot biomechanics
– Crepitus(severe cases)
– Giving way due to weak quads
• no scans in early stages (may scan if not improving)
• Outcomes: VAS, Anterior Knee Pain Scale (AKPS) (Valid and Reliable, Crossley et al., Arch. Phys. Med. Rehabil. 2004 85(5) p815) , GROC, Functional outcomes (ROM, strength, running)

28
Q

PFPS evidence

A

• RCT arthroscopy + exercise vs. exercise alone (9 month follow-up) (Kettunen et al., BMC Medicine
2007 5, article #38)
• Both groups treated with 8 week exercise program
• No difference between groups at follow-up (Kujala Score and VAS)
• Arthroscopy cost exceeded exercise group by €901/patient
• Collins et al., Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. BJSM 2009 43(3), p169

29
Q

PFP

A

• Gradual onset of retropatellar or peripatellar pain
PFP
• Aggravated by tasks that increase patellofemoral joint (PFJ) loading
– Such as jumping, running, squatting, stairs, prolonged sitting
• Justtoclarify,itISNOT
– Chondromallacia patella
– Patellar tendinopathy
– Osgood Shclatters
– Sinding Larsen-Johansson’s disease – Bursitis
– Plural of neuromas
– Intra-articular pathology
– Plica syndrome
– And other rarely occurring pathologies of knee…

30
Q

PFP differentiation

A

• Themostcommon alternative diagnosis you need to differentiate is
– Patellar tendinopathy
• The S&S will vary ever so slightly…

31
Q

PFP contributing factors

A 
• Extrinsic factors
– Excessivetrainingload, altered training surface, incorrect footwear
• Intrinsic factors – Gender?
– Local
• knee
– Proximal
• Hip, thigh, pelvis, trunk
– Distal
• Footandlowerleg
32
Q

Intrinsic risk factors of PFP

A

– Proven association with (Lankhorst, 2012)
– Larger Q angle (quads angle)
• But measuring protocol needs clarification
– Sulcus sign/angle – Patella tilt angle
• Which direction??
– Lower knee peak extension torque – ê hip abd strength as a %BW
– ê hip ER strength
• Prospectively (why is this important?) – Limited quads flexibility
– Limited gastroc flexibility
– Knee extensor weakness
– ê knee extension peak torques –éknee valgus moment at initial contact
• NOT a risk
– Genu varum and valgum

33
Q

PFP Rx

A

• Therearearangeof interventions that have been demonstrated to be effective in PFP Rx
– Proximal – hip abductors and ER strength
– Distal – orthoses
– Local – taping, PF mobs, vasti retraining
• Multimodal PT approach is considered gold standard Rx option with strongest evidence
– Patallataping
– Vasti retraining
– Glutealstrength
• AbductorandERstrength
– Patella mobs – Stretches
• Orthoses….

34
Q

PFP Rx success

A

• Generallyhighwithconservativetreatmentinthe short term but longer term is more questionable
– > 7 years, 30% of non-recovery patients had persistent symptoms
• Manyindividualshaveunfavourableoutcomeat3 months (55%) and 12 months (40%)
– How do we address the ‘subgroups’ and ensure our treatment becomes more targeted and effective.

Clinic (17 decks)

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